Should I fear the growing number of NPs?

[CantStop]

I'm someone who wants to go into IM and now won't be starting medical school until 2013, but all throughout these forums are concerns that the growing number of NPs will significantly stifle the growth of Internal Medicine positions. Some, however, point out that with growing retired populations, as well as the addition of 30 million new patients to the ranks of the insured, that this will create significant demand that necessitates the growing number of NPs and expanding Physician classes. Additionally, many docs will be retiring by 2020, but I just wanted to see what you guys' opinions are.

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[NurWollen]

I'm someone who wants to go into IM and now won't be starting medical school until 2013, but all throughout these forums are concerns that the growing number of NPs will significantly stifle the growth of Internal Medicine positions. Some, however, point out that with growing retired populations, as well as the addition of 30 million new patients to the ranks of the insured, that this will create significant demand that necessitates the growing number of NPs and expanding Physician classes. Additionally, many docs will be retiring by 2020, but I just wanted to see what you guys' opinions are.

I am amazed at the level of knowledge an IM doc can have, even compared to a family practitioner, not to mention a nurse practitioner. I've had some health problems, and the FP's are often at a loss as far as dosages/medications without at least consulting with an internist. (That's not a rip on FP's... they have a lot more breadth I think and a little less depth than FM) I can only imagine that the gap between IM/FP and NP is HUGE. There will always be a need for docs as long as there are sane people. I have seen docs and NPs at my schools student health clinic and I have gotten some really lousy, unscientific advice from NP's.

Then again, NP's are great for getting a refill on prescriptions, getting antibiotics for bronchitis, etc. with just a quick appointment. But for anything other than the most routine of health problems, I'd rather see an MD/DO.

That's my rant...

But to answer your question, I think that if NP's realized they will often need to consult someone with more knowledge/training, then no, I wouldn't worry about the future of physicians in primary care. But if NP's continue to insist they are just as good as a doctor, push for independent practice rights, etc, then maybe yes. They have a political advantage because it is easier for Joe Public to sympathize with a nurse than with a physician.

 

[JaggerPlate]

Every doc in every specialty should be worried.

 

[randomusername]

Every doc in every specialty should be worried.

+1

We had a pain management doc talk to our anesthesia club yesterday and he was telling us how the CRNAs in Louisiana were trying to get rights to practice pain management recently and the pain med docs luckily managed to stifle that particular attempt for now. Basically, any field that makes more than being a basic NP or CRNA is under threat until some sort of laws protecting physician practice rights are enacted.

 

[mulberry]

I think you need to read this article on CNN before changing your mind.

http://money.cnn.com/2011/03/23/new...dents_pick_family_medicine/index.htm?hpt=Sbin

 

[MightyMoose]

+1

We had a pain management doc talk to our anesthesia club yesterday and he was telling us how the CRNAs in Louisiana were trying to get rights to practice pain management recently and the pain med docs luckily managed to stifle that particular attempt for now. Basically, any field that makes more than being a basic NP or CRNA is under threat until some sort of laws protecting physician practice rights are enacted.

How about protecting the patients... I can't believe all these fields nurses are trying to muscle into in medicine... There are huuuuuge knowledge gaps between physicians and nurses whether they want to admit it or not.

I relate it to the black box phenomenon. They know if they give drug X then reaction Y occurs, but they have no idea why it does what it does... This is scary when you start to consider very sick patients.

 

[Shinken]

I've had some health problems, and the FP's are often at a loss as far as dosages/medications without at least consulting with an internist.

I have to admit this is true. As a soon-to-graduate Family Medicine doctor I have to admit, the other day I was at a loss as far as dose and medication to treat my patient. Amoxocelen? Amixocilyn? 3,000Kg per day divided qid? Or was that tid? Finally I decided to page an IM doctor who set me straight: amoxicillin at a dose of 90mg/kg/day divided bid for otitis media. Whew! he saved my butt for sure! Dosages and medications will always give me trouble as a Family doc. Thank God for internists. I had to call him back, though, because the pharmacy called me and asked "for how long?" Duh! IM to the rescue again.

(yes, sarcasm...as an FP doctor I NEVER, EVER, EVER, EVER, EVER have had to "consult an internist" about dosages/medications, and I've never heard of any of my colleagues consulting an internist about dosages or medications. Stupidity on SDN gets to me sometimes)

 

[kcin]

banana

 

[shushumiga]

I have to admit this is true. As a soon-to-graduate Family Medicine doctor I have to admit, the other day I was at a loss as far as dose and medication to treat my patient. Amoxocelen? Amixocilyn? 3,000Kg per day divided qid? Or was that tid? Finally I decided to page an IM doctor who set me straight: amoxicillin at a dose of 90mg/kg/day divided bid for otitis media. Whew! he saved my butt for sure! Dosages and medications will always give me trouble as a Family doc. Thank God for internists. I had to call him back, though, because the pharmacy called me and asked "for how long?" Duh! IM to the rescue again.

(yes, sarcasm...as an FP doctor I NEVER, EVER, EVER, EVER, EVER have had to "consult an internist" about dosages/medications, and I've never heard of any of my colleagues consulting an internist about dosages or medications. Stupidity on SDN gets to me sometimes)

right on point!

 

[RNwantDO]

I will add that nursing is working on raising the bar to DNP in 2015. Personally, I do not think it is necessary. I will soon have my ADN and this little change has helped move me to the Biomed path for my bachelors. I think this change will definitely slow down graduating rates of NP's more than they anticipated.

 

[JaggerPlate]

I will add that nursing is working on raising the bar to DNP in 2015. Personally, I do not think it is necessary. I will soon have my ADN and this little change has helped move me to the Biomed path for my bachelors. I think this change will definitely slow down graduating rates of NP's more than they anticipated.

This is no real 'bar raising' besides a bar raised in the minds of DNPs who now have the ability to pat themselves on the back in a white coat with 'Dr Noctor' written on the front of it, instead of 'Jane Noctor, NP, BS, TK, LOR, TMJ, Esq' (independent nurse practitioners always put a hilariously long line of letters after their names).

There is no increase in quality, no real addition of valid clinical experiences (on par with medical school clinical rotations), no diagnostic/basic medical science increases, etc. Long story short, nothing of real clinical value is added by moving from NP -> DNP. All it does is give NPs the ability to call themselves 'Dr,' attract more students based on this title, further muddle the line between physician and non-physician, and confuse patients (arguably purposely).

Additionally, let me be clear that the NPs are NOT the only non-physician providers who are forcefully clawing their way into medical fields (i.e. practicing medicine and surgery without having attended medical school or residency training). As of right now, the AOA and AMA are vehemently battling against the American Psychology Association who are pushing AGGRESSIVELY for prescription rights for psychologists AND the American Optometry society that is pushing for eye surgery rights for ODs (and has recently won this battle in Kentucky where optometrists can now essentially perform a WIDE range of laser and non-laser eye surgeries).

It's an issue, and anyone who tells you not to worry about it, or blathers on about 'filling gaps in care,' makes inane statements about '30 million now insured under Obamacare' is trying to make it seem like something less than a militant takeover.

A few simple steps everyone can do as of now:

1. Tell everyone you can about the issue - people (even medical students/professionals) are generally unaware

2. Donate to any physician PAC that fights to legitimately stop this crap

3. Write letters, make your opinion known to the people who matter, etc

4. When you're further along ... don't ever hire a NP/DNP to work in your office - work and heavily support PAs.

 

[Everglide]

Yes but not just because you're interested in IM. Current and future med students should do what JaggerPlate wrote above. As I was told by our PAC advisor - the NP groups are really gaining ground because the physician groups are frankly apathetic or too busy to care about the matter.

 

[randomusername]

Yes but not just because you're interested in IM. Current and future med students should do what JaggerPlate wrote above. As I was told by our PAC advisor - the NP groups are really gaining ground because the physician groups are frankly apathetic or too busy to care about the matter.

I'm curious because I don't actually know, is there a national group/PAC whose sole or primary focus is protection of physician rights? I know that groups like AMA or AAPS are active in a variety of areas including that, but it seems like physicians are experiencing a lot of "divide and conquer" maneuvers from non-physician providers that multi-issue groups like AMA cannot adequately tackle and physicians/residents/med students/patients/etc would benefit from having one single group to look to and donate to in order to help defend the physician's role as the backbone of medicine.

 

[jmanpatsfan]

There's two ways to gain practice rights in America: go to medical school or go to the legislature.
- from the DO in Oregon that went through this issue with ND's.

 

[zann0324]

"There is no increase in quality, no real addition of valid clinical experiences (on par with medical school clinical rotations), no diagnostic/basic medical science increases, etc. Long story short, nothing of real clinical value is added by moving from NP -> DNP. All it does is give NPs the ability to call themselves 'Dr,' attract more students based on this title, further muddle the line between physician and non-physician, and confuse patients (arguably purposely)."

This is definitely the most frustrating and concerning issue...we've been having many discussions about it in the ER where I work...Each time one of the NP's from the walk-in comes over to ask for a physician consult or to turf a patient...I consider chalking up a list so I can show it to them when they b**** about their rights...and let me be very clear, some patients are turfed because of rules/regs at the hospital not because of the abilities of the NP and also, I adore most of our mid-level providers--excellent, intelligent people..however, that does not detract from this issue...they are NOT on the same level as physicians

"A few simple steps everyone can do as of now:

1. Tell everyone you can about the issue - people (even medical students/professionals) are generally unaware

2. Donate to any physician PAC that fights to legitimately stop this crap

3. Write letters, make your opinion known to the people who matter, etc

4. When you're further along ... don't ever hire a NP/DNP to work in your office - work and heavily support PAs.[/QUOTE]"

I like your plan....and I say that if in the future people start using NP's as their choice when they have legitimate medical problems...well, we'll just call that natural selection (joking here!!)

P.S. Jagger---My apologies for it not showing up as quoted...Not sure what happened.

 

[Brachyury]

The reality is that the United States needs more physicians. Congress will never expand residency funding (at least not by a lot), and demand for medice will continue to grow. There will be more and more NPs and PAs, but at the same time, the role of the MD (or I guess DO in y'all cases) will change: we will handle the more complex cases, and will supervize mid-levles. The simply is just not enough money to train as many physicians as we will need in the next few decades, thus the role of physicians in health care will change over time

 

[Isoprop]

I'm trying to find an unbiased (or close to it) source about the issues and the facts surrounding this debate. I've read the blog entries/comments and some of the threads on the issue, but it's hard to wade through the politicized rhetoric that pushes an agenda from the issues and facts.

At the very least, can someone point out a well-written argument for either/both sides that uses good reasoning and proper citations instead of the self-entitlement and whining I hear from both sides.

I want to pick a side, but right now, I have too little information.

 

[MightyMoose]

I'm trying to find an unbiased (or close to it) source about the issues and the facts surrounding this debate. I've read the blog entries/comments and some of the threads on the issue, but it's hard to wade through the politicized rhetoric that pushes an agenda from the issues and facts.

At the very least, can someone point out a well-written argument for either/both sides that uses good reasoning and proper citations instead of the self-entitlement and whining I hear from both sides.

I want to pick a side, but right now, I have too little information.

Here is a great source for you:

http://tinyurl.com/4pv5vhb

 

[JaggerPlate]

The reality is that the United States needs more physicians. Congress will never expand residency funding (at least not by a lot), and demand for medice will continue to grow. There will be more and more NPs and PAs, but at the same time, the role of the MD (or I guess DO in y'all cases) will change: we will handle the more complex cases, and will supervize mid-levles. The simply is just not enough money to train as many physicians as we will need in the next few decades, thus the role of physicians in health care will change over time

Actually, this is the exact type of BS the NP armies want you to believe. I apologize if I sound like some sort of conspiracy theorist here, but the truth of the matter is that the 'mundane' cases the NPs (et. al.) want to treat are the exact type of 'bread and butter cases' that keep physicians in business.

Think about it this way - for every zebra you see during any given week, you see 50 horses before it and 50 horses after it. If you fall into their BS and give up, what you're doing is taking that 99% of your business and flushing it down the toilet. It makes no good business sense to give up the cases that keep you afloat.

Think of it like a car dealership - maybe you're the best dealer on the lot; smart, know your stuff, and qualified and good enough to sell the Ferrari when 99% of the other salesmen are only qualified to push Volvos. However, for every 99 Volvos you sell at 50k, you're able to see 5 individuals interested in seriously test driving the Ferrari and 1 who will buy it at 250k. Would you cut all your ties to the Volvo and give them all to the neophyte salesmen and focus on the .5% of Ferrari buyers out there simply because the rush is better, the payout is more, etc?

Of course not.

Furthermore, think about this:

1. Medicine is becoming so increasingly specialized that it's likely there is another 10 physicians in your local area who did a zebra fellowship and would cut your business into pieces as is.

2. All the zebras look like horses at first, hence they will go to the NPs first, get misdiagnosed 10x, and either transferred to you in a far worse state (very bad for the patient) or end up in an ER (bad for both of you).

3. What's to stop the NPs from seeing that the Zebra diagnosis and treatment pays better and lobbying for that? It's the 'give them an inch, they want a mile' mentality that's allowed NPs and ANPs to integrate fields like Anesthesia, Dermatology, Cardiology, and things like Psychologists in Psyche, ODs functioning as Ophthalmologists.

Additionally, I think you'll see things like 'physician shortage' '30 million now insured,' 'we need more practitioners,' will pan out in places like the the rural south or Idaho (where no one wants to practice - no offense - including the NPs), but try to open a FP practice in the middle of any urban city and tell me you feel like your services are in short supply.

Again, just don't buy in to any of these justifications because it's EXACTLY the mentality that leads these discussions into deeper and deeper levels of 'you've got to be kidding me. '

Be proud of what you're earning, don't feel like you ever have to budge a millimeter, and do NOT be ashamed for a second to admit that you want to earn and provide for yourself and your loved ones. Most importantly though, don't be afraid to stand up for the patients we're all supposed to be treating in the first place. Like someone else said earlier, the current differences between the training models are staggering, and patients suffer in the end.

 

[Brachyury]

Actually, this is the exact type of BS the NP armies want you to believe. I apologize if I sound like some sort of conspiracy theorist here, but the truth of the matter is that the 'mundane' cases the NPs (et. al.) want to treat are the exact type of 'bread and butter cases' that keep physicians in business.

Think about it this way - for every zebra you see during any given week, you see 50 horses before it and 50 horses after it. If you fall into their BS and give up, what you're doing is taking that 99% of your business and flushing it down the toilet. It makes no good business sense to give up the cases that keep you afloat.

Think of it like a car dealership - maybe you're the best dealer on the lot; smart, know your stuff, and qualified and good enough to sell the Ferrari when 99% of the other salesmen are only qualified to push Volvos. However, for every 99 Volvos you sell at 50k, you're able to see 5 individuals interested in seriously test driving the Ferrari and 1 who will buy it at 250k. Would you cut all your ties to the Volvo and give them all to the neophyte salesmen and focus on the .5% of Ferrari buyers out there simply because the rush is better, the payout is more, etc?

Of course not.

Furthermore, think about this:

1. Medicine is becoming so increasingly specialized that it's likely there is another 10 physicians in your local area who did a zebra fellowship and would cut your business into pieces as is.

2. All the zebras look like horses at first, hence they will go to the NPs first, get misdiagnosed 10x, and either transferred to you in a far worse state (very bad for the patient) or end up in an ER (bad for both of you).

3. What's to stop the NPs from seeing that the Zebra diagnosis and treatment pays better and lobbying for that? It's the 'give them an inch, they want a mile' mentality that's allowed NPs and ANPs to integrate fields like Anesthesia, Dermatology, Cardiology, and things like Psychologists in Psyche, ODs functioning as Ophthalmologists.

Additionally, I think you'll see things like 'physician shortage' '30 million now insured,' 'we need more practitioners,' will pan out in places like the the rural south or Idaho (where no one wants to practice - no offense - including the NPs), but try to open a FP practice in the middle of any urban city and tell me you feel like your services are in short supply.

Again, just don't buy in to any of these justifications because it's EXACTLY the mentality that leads these discussions into deeper and deeper levels of 'you've got to be kidding me. '

Be proud of what you're earning, don't feel like you ever have to budge a millimeter, and do NOT be ashamed for a second to admit that you want to earn and provide for yourself and your loved ones. Most importantly though, don't be afraid to stand up for the patients we're all supposed to be treating in the first place. Like someone else said earlier, the current differences between the training models are staggering, and patients suffer in the end.

I'll offer to two things: this http://www.thecrimson.com/article/2007/10/22/med-school-keeps-class-size-steady/

And this article which looks at slashed enrollment at public and private institutions http://www.insidehighered.com/news/2010/03/04/medschools

I agree with you 100%, but there is not, and will not, be money to train more physicians.

I don't want to sound like jerk here, but let me rant: I'm at an allo school that has expanded ~20% over the past decade in response to the AAMC's call for a 25% expansion at all allo schools. The school cannot expand any more without compromising 3rd and 4th year education. In the first link, schools such as Dartmouth cannot expand because the medical school hemorrhages money left-and-right, and were it not for their hospital, Dartmouth's med school would most likely fold. Or you have a situation such as this where even a 100 million endowment isn't enough to start a new medical school http://www.mlive.com/news/kalamazoo/index.ssf/2011/03/wmu_receives_100_million_anony.html
We could continue to expand osteo schools because COCA isn't as stringent (i.e. not as anal about endowments and research funding/facilities), but the downside, of course, is that COCA isn't as stringent about requiring schools to have high-quality rotation sites (i.e. instead of encouraging schools to have quality rotation sites like CCOM and PCOM, they allow schools to send their students to the four-corners of the Earth to learn medicine in a preceptor-based approach). It's not as if newer osteo school have not looked for quality hospitals to be affiliated with, but the infrastructure to train more medical students (partially due to not existing and partially due to turf) does not exist.

All these situations point to the fact that educating more medical students isn't easy, and without more residencies, expanding the number of med students will not solve the problem. The ideal situation would be to increase residencies and to increase the number of MD and DO students each year while continuing to allow IMGs and FMGs to fill the remaining spots.

I apologize if I offended anyone; it was not my intention

 

[JaggerPlate]

You didn't offend anyone (as far as I can tell), and I hope you didn't take my post that way. I was just ranting, it wasn't directed at you. I apologize if it was taken this way.

I agree with everything you've said - it's tough to open/expand medical schools in the traditional model, and that's why more and more schools (for better or worse) are starting to look at the way DO schools expand, specifically the 3/4 year rotations. The most recent Macy report on medical school expansion (from 2010) essentially said that all new schools (MD and DO) are likely to utilize this model.

Frankly, it's just impossible to get some sort of huge, university affiliated, non-profit hospital off the ground and attach a medical program within any reasonable time frame. Additionally, as you pointed out, expansion of current programs isn't easy either. I personally think DO schools will keep expanding at 3-5x the rate of MD programs.

However, this doesn't take a few things into account:

1. Creating a bunch of more doctors each year won't solve this because ...

a.The areas that are legitimately suffering shortages of care are the areas that no one wants to practice at in the first place. You can create a 1000 new docs to tackle a PC shortage in rural Mississippi, but if none of them want to live and work there, it makes no difference. Additionally, the areas where all the new docs (with 6 figure salaries and the idea of the MD lifestyle) want to live are urban, and have a shortage of nothing. Like I said, look at an area like Los Angeles, New York, Atlanta, Miami, etc, and tell me they are suffering??

b. No one is going into the primary care fields where we need docs. Increasing class sizes is just making it harder to become a dermatologist, and FORCING some people into PC fields, which I personally have mixed feelings about (and I attribute, more than anything, the recent increase in FM volume to).

2. The NPs/DNPs have absolutely 0 interest filling a gap in primary care. Zero, zlitch, none. It's a sound byte they use when lobbying congress. Look at the evidence - residencies in "nursing dermatology" (gag), CRNAs, NPs in Cardiology, pushing for more rights in pain management, etc, etc, etc. What are they filling a gap in ... the crucial need for more cosmetic dermatology providers in Beverly Hills?

What I'm trying to say is increasing the number of these guys isn't going to do anything worthwhile, because they aren't going to address these problem areas.

I'll offer to two things: this http://www.thecrimson.com/article/2007/10/22/med-school-keeps-class-size-steady/

And this article which looks at slashed enrollment at public and private institutions http://www.insidehighered.com/news/2010/03/04/medschools

I agree with you 100%, but there is not, and will not, be money to train more physicians.

I don't want to sound like jerk here, but let me rant: I'm at an allo school that has expanded ~20% over the past decade in response to the AAMC's call for a 25% expansion at all allo schools. The school cannot expand any more without compromising 3rd and 4th year education. In the first link, schools such as Dartmouth cannot expand because the medical school hemorrhages money left-and-right, and were it not for their hospital, Dartmouth's med school would most likely fold. Or you have a situation such as this where even a 100 million endowment isn't enough to start a new medical school http://www.mlive.com/news/kalamazoo/index.ssf/2011/03/wmu_receives_100_million_anony.html
We could continue to expand osteo schools because COCA isn't as stringent (i.e. not as anal about endowments and research funding/facilities), but the downside, of course, is that COCA isn't as stringent about requiring schools to have high-quality rotation sites (i.e. instead of encouraging schools to have quality rotation sites like CCOM and PCOM, they allow schools to send their students to the four-corners of the Earth to learn medicine in a preceptor-based approach). It's not as if newer osteo school have not looked for quality hospitals to be affiliated with, but the infrastructure to train more medical students (partially due to not existing and partially due to turf) does not exist.

All these situations point to the fact that educating more medical students isn't easy, and without more residencies, expanding the number of med students will not solve the problem. The ideal situation would be to increase residencies and to increase the number of MD and DO students each year while continuing to allow IMGs and FMGs to fill the remaining spots.

I apologize if I offended anyone; it was not my intention

 

[Everglide]

Or you have a situation such as this where even a 100 million endowment isn't enough to start a new medical school http://www.mlive.com/news/kalamazoo/index.ssf/2011/03/wmu_receives_100_million_anony.html

Actually that 100m was more than enough to not only start a medical school that will "open in two years" but also force out the existing students who rotate there (MSU CHM)... not that we need more med students since in 2014 we should be reaching more graduates than GME slots.

 

[CantStop]

Actually that 100m was more than enough to not only start a medical school that will "open in two years" but also force out the existing students who rotate there (MSU CHM)... not that we need more med students since in 2014 we should be reaching more graduates than GME slots.

I don't think your claim is correct about 2014.

 

[scpod]

....The NPs/DNPs have absolutely 0 interest filling a gap in primary care. Zero, zlitch, none. It's a sound byte they use when lobbying congress. Look at the evidence - residencies in "nursing dermatology" (gag), CRNAs, NPs in Cardiology, pushing for more rights in pain management, etc, etc, etc. What are they filling a gap in ... the crucial need for more cosmetic dermatology providers in Beverly Hills?....

That's a really good point. I was reading an article not long ago that said in 2008 only about 35% or so of mid-levels chose to do primary care. There were no sources, so I'm not sure where the statistic came from. But, if this is really true, then the whole basis they are using for their arguments are total BS. I can say that we have tons of NP and PA students rotating through our hospital. I haven't met one this year that wants to do primary care.

 

[NurWollen]

I have to admit this is true. As a soon-to-graduate Family Medicine doctor I have to admit, the other day I was at a loss as far as dose and medication to treat my patient. Amoxocelen? Amixocilyn? 3,000Kg per day divided qid? Or was that tid? Finally I decided to page an IM doctor who set me straight: amoxicillin at a dose of 90mg/kg/day divided bid for otitis media. Whew! he saved my butt for sure! Dosages and medications will always give me trouble as a Family doc. Thank God for internists. I had to call him back, though, because the pharmacy called me and asked "for how long?" Duh! IM to the rescue again.

(yes, sarcasm...as an FP doctor I NEVER, EVER, EVER, EVER, EVER have had to "consult an internist" about dosages/medications, and I've never heard of any of my colleagues consulting an internist about dosages or medications. Stupidity on SDN gets to me sometimes)

Ok, so I did come across as a bit of a tool. Touche. And to be honest those IM docs have had to call an endocrinologist, too.

Maybe this highlights what is so disturbing about the DNP's... they don't want to refer you to someone more specialized, like any good physician would. After all, so they claim, DNP's are just as good as doctors.

 

[cbrons]

I have to admit this is true. As a soon-to-graduate Family Medicine doctor I have to admit, the other day I was at a loss as far as dose and medication to treat my patient. Amoxocelen? Amixocilyn? 3,000Kg per day divided qid? Or was that tid? Finally I decided to page an IM doctor who set me straight: amoxicillin at a dose of 90mg/kg/day divided bid for otitis media. Whew! he saved my butt for sure! Dosages and medications will always give me trouble as a Family doc. Thank God for internists. I had to call him back, though, because the pharmacy called me and asked "for how long?" Duh! IM to the rescue again.

(yes, sarcasm...as an FP doctor I NEVER, EVER, EVER, EVER, EVER have had to "consult an internist" about dosages/medications, and I've never heard of any of my colleagues consulting an internist about dosages or medications. Stupidity on SDN gets to me sometimes)

I think the dude meant FP as in Family Nurse Practitioner?

 

[87DO15]

Actually that 100m was more than enough to not only start a medical school that will "open in two years" but also force out the existing students who rotate there (MSU CHM)... not that we need more med students since in 2014 we should be reaching more graduates than GME slots.

I think there will be around 24-25000 US MD+DO by 2015, and around 25000 US MD alone by 2020 or so. The 30% increase was supposed to happen by 2015, but a report recently said that it was likely to be 21% instead.

 

[NurWollen]

I think the dude meant FP as in Family Nurse Practitioner?

No, he was responding to my unintentional slam on FP's.

 

[absolutdokta]

Here is a great source for you:

http://tinyurl.com/4pv5vhb

haha, I like this

 

[Atom bum]

How many of you guys have actually heard anything from actual physicians about this? I think it is a non-issue created by neurotic premeds worried about their compensation.

 

[Sinfest]

How many of you guys have actually heard anything from actual physicians about this? I think it is a non-issue created by neurotic premeds worried about their compensation.

It is most definitely not a non-issue created by premeds. I've heard plenty of physicians talk about the encroaching done by DNP's/CRNA's/etc.

 

[Atom bum]

It is most definitely not a non-issue created by premeds. I've heard plenty of physicians talk about the encroaching done by DNP's/CRNA's/etc.

Well that's different then. Personally, none of the physicians I have talked to care even a little.

The medical system in America needs a change regardless. I'm not saying NPs should be given full rights to practice, I'm just saying they serve a needed role.

I'm sure I will get flak for this POV... Oh well though.

 

[Sinfest]

Well that's different then. Personally, none of the physicians I have talked to care even a little.

The medical system in America needs a change regardless. I'm not saying NPs should be given full rights to practice, I'm just saying they serve a needed role.

I'm sure I will get flak for this POV... Oh well though.

NP's, along with all other mid-level providers, do provide an important role in the health care team. It is when they attempt to overstep their boundaries and acquire more responsibility than they can handle/deserve that it becomes an issue.

Try speaking to a new or soon to be anesthesiologist regarding how they feel about CRNA's.

 

[cbrons]

I start M1 at an MD school in August. I am from a rural area, with intentions to serve rural communities as a PCP. I have been around here the past 5 years with strong networking ties to the hospital and most of the physicians. I will tell you that the few doctors still working in these areas are very concerned.

In fact, it was interesting when I read the quarterly newsletter our hospital released today. The physician recruiter had a whole article on page 2 about his recruitment efforts, how he is seeking physicians in ENT, Psych, Urology, announced a new pediatrician, a couple of new family meds, etc. Then he had an entire section about his NP recruitment efforts. The language he used says it all: "In addition to our physician recruitment drive, we are also seeking qualified mid-level practitioners who will work under the direct supervision of a physician." He words it that way because he gets an ear full from the doctors at the monthly medical society meetings and knows they are all worried about scope of practice issues.

Interestingly I also recently met a girl whose mom is an NP in our area. It's a small town so just by her last name I knew who her mother was. Anyway, she told me that her mom is "a doctor." Actually she is not, she is an NP who works in within the family medicine practice here in town. But does she know the difference? No. The patients? Maybe most do but many probably not.

 

[Atom bum]

Try speaking to a new or soon to be anesthesiologist regarding how they feel about CRNA's.

I have actually, more than one even. None of them cared.

 

[Sinfest]

I have actually, more than one even. None of them cared.

Surprises me they don't care about job opportunities and security, or the fact someone less educated and less prepared than them is doing their job.

 

[JaggerPlate]

Atom,

It's not that these docs don't care or that they see it as a non-issue, honestly, check out the Gas boards for confirmation. It's the #1 thing discussed there, without a doubt and their opinions on the matter dwarf mine.

It's more that doctors are so isolated and focused in their own little microcosm, that between 70 hour work weeks, dealing with insurance reimbursement paperwork, running an office, seeing patients in inpatient centers, keeping up on CME, etc, etc, etc ... they don't have a lot of free time to roam the interweb and discuss these issues.

Additionally, the topic is discussed fairly frequently from the AMA and the AOA blog has stuff about it all the time. It's an issue, plain and simple, and, like others have said, no one here is advocating for the elimination of mid-levels, but people ARE taking issue with the rapid expansion, push for greater scope, overstepping bounds with no regard to patient care, completely independent practice etc, etc, etc.

It's funny you mention doctors not caring too because the PD of the Anesthesiology residency at our hospital came and gave a lecture to the OMS-1s at the starting of the year, and I don't remember what the original topic was, but it was essentially a 50 minute lecture on CRNAs and she shared 100% of the view points expressed here.

 

[Atom bum]

Atom,

It's not that these docs don't care or that they see it as a non-issue, honestly, check out the Gas boards for confirmation. It's the #1 thing discussed there, without a doubt and their opinions on the matter dwarf mine.

It's more that doctors are so isolated and focused in their own little microcosm, that between 70 hour work weeks, dealing with insurance reimbursement paperwork, running an office, seeing patients in inpatient centers, keeping up on CME, etc, etc, etc ... they don't have a lot of free time to roam the interweb and discuss these issues.

Additionally, the topic is discussed fairly frequently from the AMA and the AOA blog has stuff about it all the time. It's an issue, plain and simple, and, like others have said, no one here is advocating for the elimination of mid-levels, but people ARE taking issue with the rapid expansion, push for greater scope, overstepping bounds with no regard to patient care, completely independent practice etc, etc, etc.

It's funny you mention doctors not caring too because the PD of the Anesthesiology residency at our hospital came and gave a lecture to the OMS-1s at the starting of the year, and I don't remember what the original topic was, but it was essentially a 50 minute lecture on CRNAs and she shared 100% of the view points expressed here.

First off, I appreciate your level headed response. I realize this is a "hot topic" and it can be easy to get upset.
Second, based purely on what I see and hear in the news and just talking with random people this topic never comes up. I think there are other problems we as physicians and future physicians need to face before we should worry about this. That's just my point of view though so I will take it out of this thread where it really has no bearing.

 

[Trolking]

41 Wendie Howland RN MN CRRN CCM CNLPC March 13, 2010 at 10:57 am Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD. So let’s not be, umm, snotty and relegate your faint praise to URIs and well-baby care (although they are better at those too).


here's a response from an np. With that many letters after her name she has to be more qualified than an MD/DO. After I graduate I'm going to sign my name like this 'Dr. McCoy DO BS AS CNA AUA CP A&P AAT'

 

[Sinfest]

Wendie Howland RN MN CRRN CCM CNLPC

What a self-absorbed b***h

 

[mydogtobbi]

I start M1 at an MD school in August. I am from a rural area, with intentions to serve rural communities as a PCP. I have been around here the past 5 years with strong networking ties to the hospital and most of the physicians. I will tell you that the few doctors still working in these areas are very concerned.

In fact, it was interesting when I read the quarterly newsletter our hospital released today. The physician recruiter had a whole article on page 2 about his recruitment efforts, how he is seeking physicians in ENT, Psych, Urology, announced a new pediatrician, a couple of new family meds, etc. Then he had an entire section about his NP recruitment efforts. The language he used says it all: "In addition to our physician recruitment drive, we are also seeking qualified mid-level practitioners who will work under the direct supervision of a physician." He words it that way because he gets an ear full from the doctors at the monthly medical society meetings and knows they are all worried about scope of practice issues.

Interestingly I also recently met a girl whose mom is an NP in our area. It's a small town so just by her last name I knew who her mother was. Anyway, she told me that her mom is "a doctor." Actually she is not, she is an NP who works in within the family medicine practice here in town. But does she know the difference? No. The patients? Maybe most do but many probably not.

You'd be surprised. I have patients that know the difference between a medical assistant, lpn/lvn, adn , Bsn , NP and PA. They read up on these degrees. Some patients will get offended if you as their doctor refer to their medical assistants as nurses. One patient told one of the other doctors in our practice, "I thought a medical assistant goes to school for 6 months, while a nurse has a college education and must be licensed to practice; why is everyone referring to MAs as nurses." So there are many patients that do know the differences in healthcare education. Just out of interest some read up on healthcare careers.

 

[cbrons]

41 Wendie Howland RN MN CRRN CCM CNLPC March 13, 2010 at 10:57 am Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD. So let's not be, umm, snotty and relegate your faint praise to URIs and well-baby care (although they are better at those too).


here's a response from an np. With that many letters after her name she has to be more qualified than an MD/DO. After I graduate I'm going to sign my name like this 'Dr. McCoy DO BS AS CNA AUA CP A&P AAT'

Lol... I mean, really. What research is she referring to?

 

[OzelloPiRat]

The DNP is getting a hard launch off the ground tho. There is no way they will replace NPs by 2015. Here at USF they only have 12 slots a year, thus far. They got apps from over 1500. One of my buddy D.O.'s over heard another RN trying to tell me going to med school was not worth it, and to get the DNP (not at all what I want!). His statement, "So, is she a nurse, or a doctor, or a noctor? What is the limit of her practice? How will it change, as opposed to an NP? That is not what she wants. It will not use her abilities to the best level." The DNP is just another year of busy work and papers. I asked and never did receive a good answer, on how it will make you a better clinician. But it is being pushed. Even in my small town, Docs are hiring NPs instead of fellow Docs in their practice. Is this bc of funding? Or because no one wants to goto a small, quiet, Florida town? I don't know the answer, but it is a concern.

 

[taylormade2006]

You'd be surprised. I have patients that know the difference between a medical assistant, lpn/lvn, adn , Bsn , NP and PA. They read up on these degrees. Some patients will get offended if you as their doctor refer to their medical assistants as nurses. One patient told one of the other doctors in our practice, "I thought a medical assistant goes to school for 6 months, while a nurse has a college education and must be licensed to practice; why is everyone referring to MAs as nurses." So there are many patients that do know the differences in healthcare education. Just out of interest some read up on healthcare careers.

In contrast, I've encountered numerous patients that refer to their NPs as their doctors.

 

[cbrons]

[2011-03-28 15:58:48] <cbrons`office> the real problem is, as I once heard someone say, "A little knowledge is a very dangerous thing."

[2011-03-28 15:58:52] <david06> yup

[2011-03-28 15:59:06] <david06> the best part is they think they know more than the vast majority of drs

[2011-03-28 15:59:16] <david06> they think they are more qualified than primary care docs at least

[2011-03-28 15:59:23] <david06> to address sports related issues

[2011-03-28 15:59:40] <david06> yet when it comes down to it

[2011-03-28 15:59:51] <david06> the fact that they can't even dispense ibuprofen to their atheletes

[2011-03-28 15:59:52] <cbrons`office> If you teach your average person the different parts of the spine and throw in a few symptoms associated with certain diseases, and then ON TOP OF THAT give them a CERTIFICATE, DEGREE or a TITLE, they already are empowered to believe they have more knowledge and capabilities than they actually do

[2011-03-28 16:00:02] <david06> that says it all
[2011-03-28 16:00:09] <david06> yup

[2011-03-28 16:00:13] <ts> sounds hot

[2011-03-28 16:00:15] <david06> they get fancy letters they can put after their name

[2011-03-28 16:00:29] <ts> get me the exclusive rights to this girl and we have a deal

[2011-03-28 16:00:38] <david06> i forwarded an email to myself from work today just because of the subject line

[2011-03-28 16:00:51] <david06> the chief nursing officer is leaving for a new job

[2011-03-28 16:01:05] <david06> the subject line is Jane Doe, Ph.D., R.N., N.E.-B.C., Chief Nursing Officer

[2011-03-28 16:01:10] <cbrons`office> if you look at Therapist4Change's signature, it says "When you get a BA, you think you know everything. When you get a PhD, you realize how much you don't know."

[2011-03-28 16:01:19] <cbrons`office> yeah thats ridiculous

[2011-03-28 16:01:22] <cbrons`office> titles and letters

[2011-03-28 16:01:29] <david06> with nothing to actually back them up

[2011-03-28 16:02:12] <cbrons`office> U give someone a few letters for a 6 month watered down class with a big textbook that has a few medical terms in it, they think they are already benjamin rush and jonas salk combined

 

[Brachyury]

I have actually, more than one even. None of them cared.

Re: CRNAs, I've had the exact same experience with anesthesiologists over-and-over-and-over again. On a personaly basis, everything is cordial, it's only a pissing contest between CRNA and anesthesiology lobying and national groups.

Talk to PP and academic anesthesiologists: from my expereince, the views on the gas forum do not represent the views of all anesthesiologists

 

[CantStop]

I'm probably being overly cautious, but how will this affect docs (IM docs, in my case)? Doctors are pretty much used to 100% employment, do you guys think this will drastically change over the next decade, even with the aging population and new insured patients? I'm just worried about graduating med school, finishing residency, and not being able to find a decent paying job (180K, which is the average now for IM docs, I believe). Sorry for being OCD, but these are apparently real concerns.

 

[JaggerPlate]

I'm probably being overly cautious, but how will this affect docs (IM docs, in my case)? Doctors are pretty much used to 100% employment, do you guys think this will drastically change over the next decade, even with the aging population and new insured patients? I'm just worried about graduating med school, finishing residency, and not being able to find a decent paying job (180K, which is the average now for IM docs, I believe). Sorry for being OCD, but these are apparently real concerns.

In my opinion, it's very, very unlikely that docs - especially generalists, will ever really be hurting for employment. This doesn't mean it can't happen - research some of the issues with Pathology to confirm. However, there are certain fail safes built into the system, such as medicare/medicaid, a HUGE population, a small number of docs outside of larger cities, etc, that all but guarantee you can find a job as a doc. I've heard a lot of people compare expansion, etc, to fields like law, where people are legitimately screwed, but I don't see docs, especially generalists, ever really out on the street. Now, this doesn't meant that the job would be ideal, but I'd say extreme scenario, move outside of a big city, accept medicaid and medicare, and you'll be alright.

However, this really isn't what the NP issue is all about. Again, resorting to compromises like 'well, at least we will have work' (which I'm not saying you're doing) is the type of mindset that allows for takeover. You're going to give up a minimum of 7 years and 200k to become a doc ... don't do so with the hopes that you'll simply be able to 'get a job.'

 

[CantStop]

In my opinion, it's very, very unlikely that docs - especially generalists, will ever really be hurting for employment. This doesn't mean it can't happen - research some of the issues with Pathology to confirm. However, there are certain fail safes built into the system, such as medicare/medicaid, a HUGE population, a small number of docs outside of larger cities, etc, that all but guarantee you can find a job as a doc. I've heard a lot of people compare expansion, etc, to fields like law, where people are legitimately screwed, but I don't see docs, especially generalists, ever really out on the street. Now, this doesn't meant that the job would be ideal, but I'd say extreme scenario, move outside of a big city, accept medicaid and medicare, and you'll be alright.

However, this really isn't what the NP issue is all about. Again, resorting to compromises like 'well, at least we will have work' (which I'm not saying you're doing) is the type of mindset that allows for takeover. You're going to give up a minimum of 7 years and 200k to become a doc ... don't do so with the hopes that you'll simply be able to 'get a job.'

I get what you're saying. The large increase in NPs and their responsibilities will eventually slow salary raises for Physicians, especially if they're doing procedures.

 

[NurWollen]

In my opinion, it's very, very unlikely that docs - especially generalists, will ever really be hurting for employment. This doesn't mean it can't happen - research some of the issues with Pathology to confirm. However, there are certain fail safes built into the system, such as medicare/medicaid, a HUGE population, a small number of docs outside of larger cities, etc, that all but guarantee you can find a job as a doc. I've heard a lot of people compare expansion, etc, to fields like law, where people are legitimately screwed, but I don't see docs, especially generalists, ever really out on the street. Now, this doesn't meant that the job would be ideal, but I'd say extreme scenario, move outside of a big city, accept medicaid and medicare, and you'll be alright.

However, this really isn't what the NP issue is all about. Again, resorting to compromises like 'well, at least we will have work' (which I'm not saying you're doing) is the type of mindset that allows for takeover. You're going to give up a minimum of 7 years and 200k to become a doc ... don't do so with the hopes that you'll simply be able to 'get a job.'

Yeah, but will docs always be able to break even on medicaid and medicare? I have had doctors tell me they can't even break even on the cost of supplies for some procedures.

I like the second bolded statement. Very good point.